Benefits
Overview
CPS N EW H IRE B ENEFITS E NROLLMENT G UIDE
Congratulations on your recent employment with the Chicago Public Schools!
Congratulations, and welcome to CPS! The CPS Talent Office offers a competitive benefits package to
ensure employees have the tools to maximize overall health and well-being. Our robust benefits lineup includes five medical plan options, two dental plan options, basic and enhanced vision, a
comprehensive wellness program, an employee assistance program, short term and long term
disability, life insurance, personal accident insurance, flexible spending accounts, a supplemental
retirement savings plan, and a group legal benefit. We encourage you to take advantage of all we
have to offer.
If you are eligible for benefits, you will be able to make your benefits elections 31 days following your
date of hire. On your first day of employment you may elect benefits for yourself, your spouse/same
sex domestic partner/civil union spouse, and dependents. To complete the enrollment process, you
will need to provide an original certified birth certificate for your dependent children and/or an
original certified marriage certificate for your spouse, if applicable, within 31 days following your date
of hire. If you wish to add a same sex domestic partner or civil union partner, refer to the
documentation requirements on page 19 of this guide for detailed instructions on required
documentation. Please contact the Talent Employee Solutions Team (773-553-HR4U) if you have
questions regarding benefits enrollment. Coverage goes into effect the first day of the month
following your date of hire.
Please login to hr4u.cps.edu and follow the steps described on the following page of this New Hire
Guide to complete your benefits enrollment.
NOTE: If you do not enroll for benefits coverage within 31 days after your hire date, you will not be
able to enroll in benefits until the next open enrollment period, which means your benefits coverage
would not take effect until January 1 of the following calendar year.
Please read this Benefits Overview/Benefits New Hire Guide to understand the benefits that are
available to you and for instructions on how to complete the enrollment process.
If you have any questions, call 773-553-HR4U (4748). One of our representatives will be happy to
assist you.
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2013 CPS Benefits New Hire Packet
STEP ONE – PREPARE
Know your username and password. Your username and password for benefits enrollment are the same as
your CPS email username and password. To access your username and/or password, visit the CPS password
management website at https://password.cps.k12.il.us or call 3-EXCL (773-553-3925) for help.
Understand your benefits. Read the information in this Benefits New Hire Enrollment Guide. NOTE: To
prepare for online enrollment you may wish to make notes and have them handy when you are ready to
enroll.
Select your choices. You may choose from five medical plans, two dental plans, an enhanced vision plan, life
insurance, personal accident insurance, long-term disability, group legal, group financial, and flexible spending
accounts.
Select your primary care physician.
If you are enrolling in BlueCross HMO IL:
• You must obtain the three-digit group/IPA # that corresponds with your primary care physician by
visiting www.bcbsil.com/providers/index.htm.
• Select the HMO Illinois provider network.
• You may select a separate group/IPA# for each of your eligible dependents.
• Your primary care physician and your women’s principal healthcare provider (OB/GYN) must be in the
same site.
If you are enrolling in UnitedHealthcare HMO:
• You must obtain the 13–digit primary care physician ID by visiting www.myuhc.com.
• Select the UnitedHealthcare Select EPO network.
• You may select a separate provider ID for each of your eligible dependents.
• Your primary care physician and your women’s principal healthcare provider (OB/GYN) can be in
separate sites as long as both physicians are within the participating network.
NOTE: PPO members do not need to pre-select a primary care physician.
If you are enrolling in Delta Dental HMO:
• You must obtain the facility number that corresponds with your provider name by visiting
www.deltadentalil.com. Select Delta Care USA for the listing of the HMO dental providers.
STEP TWO – ENROLL
You are ready to enroll. If you are taking advantage of benefits enrollment:
a)
To make your benefit elections, login to hr4u.cps.edu.
b)
Click “My Benefits.”
c)
Click “New Hire Benefits Enrollment” under “Quick Links” on the left side of the page.
d)
Make your elections.
e)
After you have made your elections, click “Submit” to finalize your enrollment.
S TEP T HREE – AFTER YOU E NROLL
Document Submission: To complete your enrollment, you may need to submit additional documentation. A
summary of required documentation is included on page 19 of this New Hire Guide. Required documentation
must be submitted within 31 days of your date of hire.
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2013 CPS Benefits New Hire Packet
Medical Options
CPS offers five health plan options:
BlueCross BlueShield HMO
UnitedHealthcare HMO
BlueCross BlueShield PPO
UnitedHealthcare PPO
UnitedHealthcare PPO with Heath Reimbursement Account (HRA)
There are three coverage levels available with each plan: employee only, employee + one, or family coverage. CPS
shares in the cost of coverage for this benefit.
Chicago Lives Healthy Wellness Program
All CPS employees enrolled in a CPS health plan are automatically enrolled in the Chicago Lives Healthy Wellness
Program. The wellness program offers employees and their covered spouses/domestic partners/civil union spouses free
health screenings, access to a personalized online health and well-being portal, and free telephonic health coaching.
Employees and covered spouses/domestic partners/civil union spouses who do not meet the minimum participation
requirements will be assessed a monthly $50 non-participation fee per non-participant
You will be contacted after your medical plan enrollment information is processed with instructions for completing
the first enrollment step, the Well-being Assessment (WBA)
More information regarding ongoing requirements is available at www.chicagoliveshealthy.com/CPS.
Note: New hires are not required to complete the biometric screening until the following plan year (in January and
February after the initial year of hire)
The Differences between the HMO and the PPO plans
With the Health Maintenance Organization (HMO) Plans
The premiums deducted from your paycheck are less expensive than those associated with the PPO plans.
There are no deductibles; out-of-pocket expenses are kept at a minimum. You are only required to pay the
appropriate co-pay associated with each service.
You are required to select a physician from the plan’s pre-approved list of healthcare providers and put that
provider information on file with your insurance company.
In the BCBS HMO, referrals are required from your primary care physician if you need to see a specialist.
With the Preferred Provider Option (PPO) Plans
The premiums deducted from your paycheck are slightly higher than HMO premiums.
There are deductibles, and you are required to pay co-pays.
You are afforded more flexibility with selecting a physician; you will be able to see almost any doctor you choose.
The PPO plans also have pre-approved lists of healthcare providers; however, coverage is also available when you
see a provider who is not on that pre-approved list. When you see a pre-approved doctor, you’ll save more money—
but you won’t be without coverage if you choose to see an “out-of-network” provider.
You are not required to obtain a referral from your primary care physician to see a specialist; however, approval is
required from Telligen for certain services such as MRIs, CAT scans, physical therapy, etc.
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2013 CPS Benefits New Hire Packet
Medical Plan Options
CPS offers five health/medical plan options: BlueCross BlueShield HMO, UnitedHealthcare HMO, BlueCross BlueShield
PPO, UnitedHealthcare PPO, and UnitedHealthcare PPO with Heath Reimbursement Account. Employee only, employee
+ 1, or family coverage is available. CPS shares in the cost of coverage for this benefit.
HMO Options: CPS offers two Health Maintenance Organization (HMO) options. HMOs require that you receive your medical
services only through their network providers, except in emergencies. CPS offers BlueCross BlueShield HMO IL and
UnitedHealthcare HMO.
BENEFIT HIGHLIGHTS FOR ELIGIBLE
BLUECROSS BLUESHIELD
UNITEDHEALTHCARE
EXPENSES
HMO
HMO
Annual Deductible
Out-of Pocket Maximum
Lifetime Maximum
Care in Physician’s Office
General Office Visits (e.g., X-rays, allergy
shots, and chemotherapy)
Wellness/Preventative Care (e.g., routine
physical check-ups for adults and children,
well baby care, colonoscopies,
mammograms, pap smears, PSA,
physicals, and immunizations)
In-Patient Hospital Services
Hospital (semi-private) room and board
Doctor’s visits (including specialists),
X-rays, drugs, surgeon fees, and
anesthesiologists.
Out-Patient Hospital Care (including surgery)
Maternity
Prenatal/Postnatal
N/A
N/A
Unlimited
N/A
N/A
Unlimited
100% after $30 co-pay
per visit
100% after $30 co-pay
per visit
100% no co-pay
100% no co-pay
100% after $200 co-pay per admission
100% after $200 co-pay per admission
Covered in Full
Covered in Full
Covered in Full after $175 co-pay per visit
Covered in Full after $175 co-pay per visit
100% after $30 co-pay per visit
100% after $30 co-pay per visit
100% after $200 co-pay per admission
100% after $200 co-pay per admission
100% after $125 co-pay per visit
100% after $125 co-pay per visit
100%
100%
100% after $200 co-pay per admission
100% after $200 co-pay per admission
100% after $30 co-pay per visit
100% after $30 co-pay per visit
Therapy
Physical, occupational, and speech
therapy for restoration of function
(Limited to 60 visits per calendar year per
therapy)
100% for the number of visits which, in the
judgment of the attending or consulting physicians,
are sufficient for significant improvement
100% for the number of visits which, in the
judgment of the attending or consulting
physicians, are sufficient for significant
improvement
Chiropractic care (Unlimited visits if
medically necessary)
100% after $30 co-pay
per visit
Hospital Coverage (Mother and Newborn)
Covered Emergency Care
Emergency Care (If deemed an
emergency)
Ambulance
Mental Health and Substance Abuse
(unlimited visits)
In-patient
Out-patient
Care in Skilled Nursing Facility (up to 120 days
per year if medically necessary)
Prosthetic Devices and Medical Equipment
Employee Contribution (% of Base Salary)
Eligible Full-Time Employees
Employee Contribution (% of Base Salary)
Eligible Part-Time Employees
5
100% after $30 co-pay
per visit
100%
100%
100%
100%
Employee Only:
Employee +1:
Family:
1.3%
1.5%
1.8% CTU/
Unite H.E.R.E.
Employee Only:
Employee + 1:
Family:
2.3% All Others
2.6%
3.0%
3.6%
Employee Only:
Employee +1:
Family:
2.0%
2.2%
2.5% CTU/
Unite H.E.R.E.
Employee Only:
Employee + 1:
Family:
3.2% All
Others
4.0%
4.4%
5.0%
2013 CPS Benefits New Hire Packet
PPO Options: CPS offers three Preferred Provider Organization (PPO) options. PPOs do not require that you select a
primary care physician. CPS offers BlueCross BlueShield PPO, UnitedHealthcare PPO, and UnitedHealthcare PPO with
Health Reimbursement Account.
NOTE: PPO participants or their physicians must contact Telligen at 1-888-781-9458 for review and pre-certification of certain
services and procedures, such as hospitalizations and for non-custodial care in a skilled nursing facility at least one day before an
elective admission. Penalty for failure to pre-certify: 50% capped at $1,000 per individual per event per confinement. For in-patient
mental health or substance abuse admission and to receive in-network mental health coverage call United Behavioral Health at 1800-711-6087.
BENEFIT HIGHLIGHTS FOR
ELIGIBLE EXPENSES
Annual Deductible
Out-of Pocket Maximum
Lifetime Maximum
Care in Physician’s Office
General Office Visits (e.g., X-rays, allergy
shots, and chemotherapy
Wellness/Preventative Care (e.g.,
routine physical check-ups for adults
and children, well baby care,
colonoscopies, mammograms, pap
smears, PSA, physicals, and
immunizations)
In-Patient Hospital Services
Hospital (semi-private) room and board
Doctor’s visits (including specialists),
X-rays, drugs, surgeon fees, and
anesthesiologists.
Out-Patient Hospital Care (including surgery)
Maternity
Prenatal/Postnatal
Hospital Coverage (Mother and Newborn)
Covered Emergency Care
Emergency Care (If deemed an emergency)
Ambulance
Mental Health and Substance Abuse
(unlimited visits)
In-patient
Out-patient
Therapy
Physical, Occupational and Speech
Therapy for restoration of function
(Limited to 60 visits per calendar year per
therapy)
Chiropractic care (Unlimited visits if
medically necessary)
Care in Skilled Nursing Facility (up to 120 days
per year if medically necessary)
Prosthetic Devices and Medical Equipment
Employee Contribution (% of Base Salary)
Eligible Full-Time Employees
Employee Contribution (% of Base Salary)
Eligible Part-Time Employees
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BLUECROSS BLUESHIELD PPO
IN-NETWORK
OUT-OF-NETWORK
$ 400 per person
$1,200 per family
$2,400 per person
$4,800 per family
$ 800 per person
$ 2,400 per family
N/A
UNITEDHEALTHCARE PPO
IN-NETWORK
OUT-OF-NETWORK
N/A
$ 600 per person
$1,200 per family
N/A
$2,000 per person
$4,000 per family
Unlimited
Unlimited
100% after $25 co-pay per visit
50% after deductible
100% - no co-pay, no deductible
50% after deductible
100% after $15 co-pay per visit
50% after deductible
100% - no co-pay, no deductible
50% after deductible
80% after deductible
50% after deductible
80%
50% after deductible
80% after deductible
50% after deductible
80%
50% after deductible
80% after deductible
50% after deductible
80%
50% after deductible
100% after $25 co-pay per visit
80% after deductible
100% after $125 co-pay per visit
50% after deductible
50% after deductible
$125 co-pay per visit
additional out of network
costs may apply
100% after $15 co-pay per visit
80%
50% after deductible
50% after deductible
100% after $125 co-pay per visit
$125 co-pay per visit
additional out of network
costs may apply
100% after deductible
100% after deductible
100%
100% after deductible
80% after deductible
50% after deductible
80%
50% after deductible
80% after deductible
50% after deductible
80%
50% after deductible
100% after $25 co-pay per visit
50% after deductible
80% after deductible
50% after deductible
80% after deductible
80% after deductible
Employee Only:
Employee +1:
50% after deductible
50% after deductible
2.2%
2.5%
Family:
2.8% CTU/
3.5% All Others
Unite H.E.R.E.
Employee Only:
4.4%
Employee + 1:
5.0%
Family:
5.6%
100% after $15 co-pay per visit
80%
80%
80%
Employee Only:
Employee +1:
Family:
50% after deductible
50% after deductible
50% after deductible
50% after deductible
2.0%
2.2%
2.5% CTU/
3.2% All Others
Unite H.E.R.E.
Employee Only
4.0%
Employee + 1:
4.4%
Family:
5.0%
2013 CPS Benefits New Hire Packet
UnitedHealthcare PPO w/ Health Reimbursement Account (HRA) is a medical option that provides you with a health
reimbursement account. Under this option, CPS will contribute either (i) $500 to the HRA if you enroll only yourself; or,
(ii) $1,000 if you enroll yourself and at least one other dependent. Those benefits that would otherwise be covered by
the PPO will be paid first out of the HRA. After the HRA is exhausted, then you must satisfy your deductible. After the
deductible has been met, CPS will pay 80% of in-network and 50% of out-of-network eligible expenses. If you do not
exhaust your HRA, the unused amount will be rolled over for your use in the next calendar year.
BENEFIT HIGHLIGHTS FOR ELIGIBLE
EXPENSES
Health Reimbursement Account (Employer Paid)
(NOT APPLIED TOWARD DEDUCTIBLE NOR OUT-OFPOCKET MAXIMUM)
Annual Deductible
Out-of Pocket Maximum
Lifetime Maximum
Care in Physician’s Office
General Office Visits (e.g., X-rays, allergy shots,
and chemotherapy
Wellness/Preventative Care (e.g., routine physical
check-ups for adults and children, well baby care,
colonoscopies, mammograms, pap smears, PSA,
physicals, and immunizations)
In-Patient Hospital Services
Hospital (semi-private)room and board
$500 Employee Only
$1,000 Employee + 1 and Family
$500 Employee Only
$1,000 Employee + 1 and Family
$1,000 per person after HRA is exhausted
$2,000 per person after HRA is exhausted
$2,000 per family after HRA is exhausted
$4,000 per person after HRA is exhausted
$2,250 per person
$11,500 per person
$4,500 per family
$34,000 per family
Unlimited
80% after deductible
100% - no co-pay, no deductible
50% after deductible
50% after deductible
80% after deductible
50% after deductible
Doctor’s visits (including specialists), X-rays, drugs,
surgeon fees, and anesthesiologists.
80% after deductible
50% after deductible
Out-Patient Hospital Care (including surgery)
80% after deductible
50% after deductible
80% after deductible
50% after deductible
80% after deductible
50% after deductible
Maternity
Prenatal/Postnatal
Hospital Coverage (Mother and Newborn)
Covered Emergency Care
Emergency Care (If deemed an emergency)
Ambulance
Mental Health and Substance Abuse
(unlimited visits)
In-patient
Out-patient
Therapy
Physical, occupational, and speech therapy for
restoration of function (Limited to 60 visits per
calendar year per therapy)
Chiropractic care (Unlimited visits if medically
necessary)
Care in Skilled Nursing Facility (up to 120 days per year if
medically necessary)
Prosthetic Devices and Medical Equipment
Employee Contribution (% of Base Salary)
Eligible Full-Time Employees
Employee Contribution (% of Base Salary)
Eligible Part-Time Employees
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UNITEDHEALTHCARE W/ HEALTH REIMBURSEMENT ACCOUNT
IN-NETWORK
OUT-OF-NETWORK
100% after $125 co-pay per visit
$125 co-pay per visit
Additional out-of-network costs may apply
100% after deductible
100% after deductible
80% after deductible
50% after deductible
80% after deductible
50% after deductible
80% after deductible
50% after deductible
80% after deductible
50% after deductible
80% after deductible
50% after deductible
80% after deductible
50% after deductible
Employee Only:
1.3%
Employee +1:
1.5%
Family:
1.8% CTU/Unite H.E.R.E.
2.3% All Others
Employee Only:
2.6%
Employee + 1:
3.0%
Family:
3.6%
2013 CPS Benefits New Hire Packet
UHC PPO w/HRA Examples
Example: You enroll yourself and one dependent in this option. CPS contributes $1,000 to your HRA. You and your
dependent incur $450 in eligible medical expenses during the 2013 calendar year. The $450 is paid out of the
HRA, leaving $550 in your HRA. There is no out-of-pocket expense for you in 2013. In 2014 your HRA will have
a beginning balance of $1,550 for you to use in 2014.
Example: You enroll yourself and one dependent in this option. CPS contributes $1,000 to your HRA. You and your
dependent incur $2,000 in eligible medical expenses during the year. The first $1,000 of those eligible medical
expenses is paid by the HRA. You pay the remainder. In 2014, your HRA will have a beginning balance of
$1,000 if you and your dependent continue in this option (i.e., will be replenished with $1,000 each year).
Example: You enroll yourself and one dependent in this option. CPS contributes $1,000 to your HRA. You and your
dependent incur $16,000 in in-network eligible medical expenses. The first $1,000 of those medical expenses
will be paid by the HRA. The second $2,000 will be paid by you in order to meet the deductible. You will then
pay 20% of the remainder until you pay an additional $2,500 to reach your family annual out-of-pocket
maximum. The remainder will then be paid by the plan at 100%.
Telligen Pre-Certification – Required for PPO Medical Options
Telligen manages the pre-certification process for CPS employees/dependents enrolled in the PPO health plans. Precertification is designed to help ensure that you receive quality medical care while discouraging unnecessary treatment.
To ensure that certain treatments and hospital stays are appropriate, you must obtain advance approval from the
medical professionals at Telligen. You may call 24 hours a day, seven days a week at 888-781-9458.
Telligen pre-certification is required for the following benefits:
In-patient hospital care, including acute rehabilitation confinements and surgeries
In-patient skilled nursing facility
Organ transplants
Air ambulance transportation
Certain outpatient surgeries and procedures:
o Blepharoplasty
o Breast surgeries (reduction, reconstruction, except related to mastectomy, biopsy, and lesions)
o CAT scans
o MRI
o Nasal surgery (rhinoplasty and septoplasty)
o PET scans
o Sclerotherapy and ligation, vein stripping
o Sleep studies
Hospice: in-patient and home
Occupational therapy: home and outpatient treatment center
Physical therapy: home and outpatient treatment center
Speech therapy: home and outpatient treatment center
Home nursing visits
Private duty nursing
Durable medical equipment and supplies. For example:
o Hospital beds
o Oxygen and oxygen-related equipment
o Apnea monitors
o Ventilators
o Prosthetics
o Other durable medical equipment that costs $500 or more
Infertility treatment
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2013 CPS Benefits New Hire Packet
Enteral formula (life sustaining tubal feeding)
All pregnancies (during the first three months or as soon as the pregnancy is confirmed and within two business
days after admission for delivery.
When to call: If you are in a PPO, in order to receive your maximum level of benefits, you must receive advance approval
from Telligen. The services or procedures that require approval are listed above. You must call at least seven (7) days in
advance for most services requiring pre-certification. You must call within two (2) business days after emergency
treatment or in-patient admissions. All pregnancies must be pre-certified twice: during the first three (3) months or
when the pregnancy is confirmed (if later) and again within two (2) business days after admission for delivery.
If you don’t call: If you do not call for pre-certification as required or if you do not follow the program’s
recommendations, you will be responsible for 50% of eligible charges (capped at $1,000 per individual per event per
confinement). You will pay this penalty plus the co-insurance that applies. Also, benefits could be further reduced if it is
determined that the treatment or admission is not medically necessary.
Three Examples of When to Call Telligen
Example 1
Physical Therapy (out-patient treatment center and home): Jennifer, a 32-year-old female and long-time
runner, is experiencing heel pain during her workouts. Jennifer’s physician has diagnosed her with Achilles
tendonitis and has suggested anti-inflammatory medication and ten physical therapy visits to reduce the
inflammation and help strengthen the tendon. Jennifer, her physician, a family member, or a friend must notify
Telligen and receive approval prior to receiving physical therapy services.
Jennifer has completed her initial ten physical therapy sessions, but her physical therapist thinks she would
benefit from an additional six sessions. Jennifer, her physician, physical therapist, family member, or friend
must notify Telligen and receive approval prior to receiving the additional physical therapy services.
Example 2
Out-patient procedures: Caleb, a 7-year-old, has had numerous bouts of a sore throat and neck swelling over
the past couple of years. During a recent examination, Caleb’s physician found a lump in Caleb’s neck. The lump
was not viewable with a normal x-ray so his physician has suggested that Caleb have an MRI. Because Caleb is a
minor his physician, the facility, or a family member (parent or legal guardian) must notify Telligen prior to the
scheduled date of this out-patient procedure.
Example 3
In-patient Surgery and Hospital Admission: Francine, a 55-year-old with severe osteoarthritis, is scheduled to
have knee replacement surgery. This surgery will require Francine to be in the hospital for several
days. Francine, her physician, the facility, a family member, or friend will need to notify Telligen as soon as the
admission date is scheduled to pre-certify this in-patient surgery and hospital admission.
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2013 CPS Benefits New Hire Packet
Prescription Drug Program
The Chicago Public Schools’ Prescription Drug Program offers you an easy and convenient way to purchase prescription
drugs. Eligible drugs are part of the overall medical life time maximum. The program covers eligible drugs purchased:
o At a participating pharmacy
o At a non-participating pharmacy
o By mail-order
RETAIL PROGRAM
MAIL SERVICE PROGRAM
For immediate or short-term medicine needs
For maintenance or long-term medicine needs
You can use your prescription benefit at more than
62,000 Caremark participating retail pharmacies
nationwide, including over 20,000 independent
community pharmacies.
Mail your original prescription along with the
mail service order form to Caremark. Your
medicines will be sent directly to your home.
When to Use Your Benefit
Where
Cost to You
Day Supply Limit
Maintenance Medication
Limit After 5th Fill:
To locate a Caremark participating retail pharmacy
in your area, go to www.caremark.com and use
the “Find a Local Pharmacy” search or call
Caremark Customer Care toll-free at
1-866-409-8523.
o $10 for each generic medicine
o
$15 for each generic medicine
o
$25 for each brand-name* medicine
on the drug list
o
$40 for each brand-name* medicine
on the drug list
o
$40 for each brand-name* medicine not on
the drug list
o
$60 for each brand-name* medicine not on
the drug list
30-day supply
90-day supply
On the 6th fill and subsequent fills it is 40%
or the co-pay, whichever is greater.
No limit
NOTE: When a generic is available but the pharmacy dispenses the brand-name medicine for any reason you will pay the
difference between the brand-name medicine and the generic plus the generic co-payment amount.
Web Services: Register at www.caremark.com to access tools that can help you save money and manage your
prescription benefit. To register, have your benefit ID card handy.
Non-Participating Pharmacy Feature: In most cases, you will not need to visit a non-participating pharmacy because
there are over 62,000 participating pharmacies in the Caremark Retail Program. However, if you choose to go to a nonparticipating pharmacy, you will pay 100% of the prescription price. You will then need to submit a paper claim form,
along with the original prescription receipt(s) to Caremark for reimbursement of covered expenses at:
Caremark Claims Department
P.O. Box 686005
San Antonio, TX 78268-6005
NOTE: Covered prescriptions purchased at a non-participating pharmacy will be paid at 60% of the generic drug cost.
The plan will also pay 60% of the generic drug cost if a brand-name drug is issued when a generic drug is available.
Covered Drugs: The following drugs are covered under the program:
Federal legend drugs (drugs requiring a prescription)
Compound prescriptions containing at least one legend ingredient
Insulin
Women’s contraceptives and contraceptive devices (limits and exclusions apply)
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2013 CPS Benefits New Hire Packet
Specific supplements (i.e., folic acid, iron, and fluoride)
Low-dosage aspirin
Tobacco cessation (generic only)
Infertility medications (with Prior-Authorization from Telligen)
Disposable insulin syringes/needles and diabetic supplies
Acne medication (with Prior-Authorization from Caremark for participants over the age of 24)
Growth hormones (with Prior-Authorization from Caremark)
Drugs Not Covered: The following drugs are not covered under the program:
Cosmetic drugs, such as Rogaine
Drugs available without a prescription, except insulin (exceptions apply)
Prescription drugs with an over-the-counter equivalent
Drugs for the treatment of obesity, morbid obesity, or weight-reduction purposes
Appetite suppressants
Brand contraceptives (oral and injection) and contraceptive devices where a generic equivalent is available
Medical supplies and equipment
Drugs not prescribed by a provider acting within the scope of his or her license
Experimental, investigational, or unproven drugs or therapies
Drugs provided to you by the local, state, or federal government and any drug for which payment or benefits are
provided by the local, state, or federal government (for example, Medicare)
Prescription vitamins
Oral or topical nail-fungal medication
Replacement prescription drugs resulting from loss or theft
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2013 CPS Benefits New Hire Packet
Dental Plan Options
Dental Options: CPS offers two dental plan options: Delta Dental HMO (DHMO) and Delta Dental PPO.
Delta Dental DHMO: The Dental HMO option is provided at no cost to you; CPS covers the full dental contribution
deduction for all coverage levels if you are enrolled in the Dental HMO option. Under this option, you may select a
dentist using a site code from the provider network sponsored by Delta Dental at www.deltadentalil.com.
Delta Dental PPO: If you opt to enroll in the PPO option, CPS will cover the cost of the employee only contribution; there
is an additional cost for employee +1 or family coverage. Under this PPO dental option, you may use either an innetwork or an out-of-network provider. The plan will pay a certain percentage of the PPO rate whether or not you use a
network provider.
SERVICES
Preventive
DELTA DENTAL HMO
100%
DELTA DENTAL PPO
IN-NETWORK
OUT-OF-NETWORK
80% of PPO rate
80% of PPO rate
Basic
85–75%
80% of PPO rate
80% of PPO rate
Major
70–65%
50% of PPO rate
50% of PPO rate
Deductible
None
None
$100 annually
Benefit Limit
None
$1,500 annually
Employee Only
None
None
Employee +1
None
$9.71 per pay period
Family
None
$20.56 per pay period
Individual Maximums
Employee Contributions
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2013 CPS Benefits New Hire Packet
Vision Plan Options
Basic Vision: If you are enrolled in one of Chicago Public Schools medical options, CPS provides you and your eligible
family members with Basic Vision. Vision Service Plan is the provider. You do not pay a premium for this coverage.
Enhanced Vision: You may upgrade your Basic Vision Plan for a monthly premium and receive coverage for glasses and
contacts and discounts on laser vision correction.
Basic Vision Plan
The Basic Vision Plan provides one eye exam per year for the $15 co-pay. In addition, you will receive discounts on eyewear.
Enhanced Vision Plan
You may upgrade your Basic Vision Plan for a monthly premium and receive coverage for glasses and contacts and discounts
on laser vision correction. See details below.
Exam covered in full with $15 co-pay……….……………………………………………………….……………………………………....every 12 months
Lenses covered in full………………………………………………………………………………………………………………...……...........every 12 months
Single vision, lined bifocal and lined trifocal lenses
Polycarbonate lenses for dependent children
Frame……………………………………………………………………………………………………………………………..…………………..……..every 24 months
Frame of your choice covered up to $150
Plus 20% off any out-pocket costs
~AND~
Contact Lenses…………………………………………………………………….…………………………………………….……..………….......every 12 months
Your $175 allowance applies to the cost of your contacts and the contact lens exam (fitting and evaluation). This exam is in
addition to your vision exam to ensure proper fit of contacts.
In addition, VSP has negotiated a benefit for wearers of certain types of contacts. If you qualify, the program includes a
contact lens evaluation and initial supply of replacement lenses. Learn more from your doctor or VSP.com.
Exam………………………………………………………………………...………….………………………………………………………………………………..….$15.00
Prescription Glasses………………………………...……………………...……..………………………………………………………...…...…………........$25.00
Contacts………………………………………………………………………………….………...................................................……..No co-pay applies
Glasses and Sunglasses
Average 30% savings on additional lens options, such as scratch resistant and anti-reflective coatings and progressives
20% off additional prescription glasses and sunglasses, including lens options
Contacts
15% off cost of contact lens exam (fitting and evaluation)
Available from any VSP doctor within 12 months of your last eye exam.
Laser Vision
You receive discounts for PRK, LASIK, and Custom LASIK using wave front technology. Discounts vary by location, but average
15–20% off the contracted laser center’s usual and customary price. Additionally, if the laser center is offering an even lower
temporary promotional price, you’ll receive 5% off the promotional price.
Employee only……………………………………………………………….……………………………………………………………….………………………..…..$7.40
Employee + One Dependent………………………………………….…….………………………………………………………….….……………………...$10.81
Family……………………………………...……………………………………………….…………………………………………………….…......................…$19.39
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2013 CPS Benefits New Hire Packet
Mental Health Benefits
Mental Health and Substance Abuse: If you are enrolled in any HMO or PPO, Chicago Public Schools offers help for
mental health or substance abuse problems. If you are in the UnitedHealthcare HMO or any PPO, the plan is
administered by United Behavioral Health (UBH); please call 800-711-6087 for more information. If you are in BlueCross
BlueShield HMO Illinois, please call 800-851-7498 for more information.
This benefit includes counseling and substance abuse recovery services that can help you effectively deal with stressful
and challenging situations. You may call for such personal issues as:
o
Depression
o
Anxiety and Stress
o
Alcohol Abuse
o
Anger Management
o
Drug Abuse
o
Marital Problems
o
Coping with Grief
o
Domestic Violence
o
Eating Disorders
o
Medication Management
o
Compulsive Spending
o
Compulsive Gambling
Employee Assistance Program (EAP)
As part of the Mental Health Benefit CPS offers an Employee Assistance Program (EAP) designed to assist employees in
coping with personal problems that may impact their lives, behavior, or performance. These personal issues may be
related to alcoholism, family disintegration, finances, marital conflicts, job loss, substance abuse, or stress related to job
security and school crises. The benefit provides short term counseling and referral services for employees and their
household members. This benefit is paid for by CPS and all employees enrolled in medical are eligible to utilize the EAP.
EAP services are provided in strict confidentiality. For additional information visit www.liveandworkwell.com or call 1800-711-6087.
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2013 CPS Benefits New Hire Packet
Flexible Spending Accounts (FSA)
Flex Spending Health: Allows you to set aside “pre-tax” dollars to pay for certain medical and dental expenses for you,
your spouse, and/or dependent children who are not covered by your medical and dental plans. Your annual
contribution must be between $25 and $2,500.
Flex Spending Dependent Care: Allows you to set aside “pre-tax” dollars to pay for eligible day care expenses, such as
costs for a babysitter, day camps or child care centers, for dependents under age 13 or tax dependents who are mentally
or physically incapable of caring for themselves. Your annual contribution must be between $25 and $5,000.
NOTE: Expenses have to be incurred by December 31 each calendar year, and you will have until March 31 of the
following year to submit the claims for those expenses. We recommend that you estimate your annual expenses for
your medical and dental services, as well as dependent care, prior to enrollment in this plan. Any unused amounts in
this account cannot be rolled over to the next calendar year and will be forfeited in accordance with IRS regulations.
EXAMPLE
You have $4,500 in planned medical expenses for 2013. You elect to contribute the annual maximum
amount of $2,500 for Flexible Spending Health. You will not be taxed on that $2,500. (In other words, you
fund your FSA on a pre-tax basis.) When you need to pay your co-pays for your health, you would utilize
your consumer accounts debit card, issued by Benefit Express. For other eligible medical expenses you will
submit a paper reimbursement form. If you are in the 20% tax bracket, by utilizing the tax-preferred
nature of this program, you will save approximately $500. Services totaling $2,500 must be incurred by
December 31 in order to be reimbursed, but claims may be submitted until March 31 of the following
year.
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2013 CPS Benefits New Hire Packet
Short-Term Disability
Short-Term Disability is an employer-paid benefit that will replace income lost during periods of disability resulting from
injury, illness, or pregnancy. The replacement income will provide a percentage of salary coverage during the following
timeframe:
Days 1-30: 100% of salary
Days 31-60: 80% of salary
Days 61-90: 60% of salary
Please visit https://hr4u.cps.edu for more detailed information on this policy.
Long-Term Disability
The CPS employee benefits program provides a plan that continues part of your pay while you are away from work
because of an extended illness or injury. The Long-Term Disability plan is designed to continue part of your income if you
have a medically certified disability. You have an opportunity to purchase long-term disability (LTD) insurance with two
options: a 90-day waiting period or a 180-day waiting period. Your monthly LTD benefit would be 60% of your monthly
earnings, reduced by other income. Evidence of Insurability is required to increase your coverage from the 180-day to
the 90-day option or to enroll for the first time. The program is insured through The Standard Insurance Company. The
employee pays the full premium, which is calculated based on age and annual salary.
Basic Life – Provided Free to the Employee
CPS provides basic life insurance coverage of $25,000 per eligible employee. This benefit is provided to you at no cost.
Optional Life
You may elect to purchase additional Optional Term Life Insurance in amounts equal to one to four times your annual
salary, up to $750,000. Spouse/Dependent Term Life coverage is also available for your spouse and eligible dependents.
To enroll your spouse/dependents in spouse/dependent life, you must first elect optional term life coverage. The
amount available for spousal coverage is $50,000 and for dependent coverage is $10,000. You must elect coverage for
Optional Term Life equal to or more than $25,000 before electing spouse coverage.
If you elect to increase your insurance by more than one times your annual salary in a year, you will need to provide
Evidence of Insurability. New hires can select up to the lesser of three times their covered annual earnings or $500,000
without providing Evidence of Insurability satisfactory to The Standard Insurance Company. This program is insured
through The Standard Insurance Company. The employee pays the full premium, which is calculated based on age and
annual salary.
Personal Accident Insurance
You may elect to purchase Personal Accident Insurance (PAI) that matches your Optional Term Life Insurance as well as
Spouse/Dependent Personal Accident that matches your Spouse/Dependent Life coverage. To enroll your
spouse/dependents in spouse/dependent in PAI, you must first elect optional term life coverage. The amount available
for spousal coverage is $50,000 and for dependent coverage is $10,000. You must elect coverage for Optional Term Life
equal to or more than $25,000 before electing PAI spouse coverage.
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2013 CPS Benefits New Hire Packet
Group Legal Services
The Group Legal Services insurance plan is a voluntary plan that provides you with certain paid-in-full legal benefits
when you use a network attorney through The ARAG Group. ARAG offers the following legal benefits:
A nationwide network of experienced attorneys who can help you address a wide range of legal matters – such
as contractor disputes, debt collection defense or Will preparation.
Online educational tools and resources that educate you on your legal issue and what steps to take.
Legally-valid, state-specific documents that can be easily created online to help you prevent or address more
common legal situations (i.e. Automobile Bill of Sale and Child Authorization Form).
The premium is $7.22 per pay period. For more information, please call 800-247-4184 or visit
www.ARAGlegalcenter.com and enter access code 10323cps.
Bright Start College Savings
Oppenheimer Funds offers parents an easy and convenient way to invest in their children’s college funds through payroll
deductions. For more information and enrollment instructions call 800-655-4853 or visit www.brightstartsavings.com.
Tobacco Usage Attestation
Employees that elect medical coverage are required to report tobacco usage status in the Tobacco Usage Attestation
form located in the employee self service portal (located directly below the medical plan edit button). Even if you do
not use tobacco you must select the option that states “no tobacco use” in the attestation page. Tobacco users will
incur a payroll deduction in the amount of $150 per year for employees that earn less than $30,000 and $250 per year
for employees that earn more than $30,000 per year. This additional contribution is used to help offset additional costs
imposed on the health plan due to tobacco use related health conditions. This policy is necessary to help preserve
quality health benefits for all CPS employees.
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2013 CPS Benefits New Hire Packet
CPS Supplemental Retirement Plans: 403(b) and 457 Savings Programs
These programs are established under Section 403(b) and 457 of the Internal Revenue Code and are available to
employees of tax-exempt organizations, such as public schools. This is one of the best ways to save money for your
retirement years and one of the few methods available today to defer current income taxes. You decide what
percentage of your gross annual earnings you wish to contribute for your retirement needs. Your contributions are
deducted from your pay before federal income taxes are withheld.
These tax-deferred compensation programs offer different investment styles so participants can create a well-diversified
investment strategy. Participants can choose from a menu of multiple investment styles, each of which are diversified
and have materially different expected risk and return characteristics. The program provides participants the ability to
diversify their individual accounts based on their own investment objectives.
You may start your account with as little as $10 per pay period. The contribution limits for 403(b) and 457 retirement
plans are $17,500 for 2013 if you are under age 50. If you are 50 years old or older, you are entitled to an “age 50 catchup” contribution of $5,500 for a total contribution of $23,000.
If you have at least 15 years of service with CPS, you may be eligible to contribute up to an additional $3,000 of
pensionable earnings into the 403(b) each year under a special “catch-up” provision. Please check with Great West to
determine eligibility.
Great West is the record keeper and fund provider for the CPS Supplemental Retirement Plans. For union represented
employees, you will continue to have a choice of VALIC, ING, MetLife, or Great West.
Differences between 403(b) and 457 Plans
There are two types of Supplemental Retirement Plans: 403(b) and 457. The key difference between the 403(b) and the
457 plan is the age in which you are allowed to take distributions. Under the 403(b) option, you are not allowed to
withdraw funds without penalty until you have reached age 59½. If you withdraw funds prior to age 59½, you will be
subject to a 10 percent penalty in addition to the income tax you will pay on the disbursement.
Under the 457 option, you may take penalty-free disbursements prior to age 59½ once you retire or when your
employment with CPS ends. However, you are not allowed to withdraw funds prior to separation from CPS.
Under both plans, you are required to begin taking disbursements at age 70½, and disbursements are subject to income
tax.
Enrolling in the 403(b)/457 saving plan
To begin saving for your retirement through payroll deductions, visit www.cpsretirementplans.com or call (877) 6494338. New hires will receive a PIN number in the mail that must be entered in order to create an account online, specify
deduction amounts, and select and investment fund(s).
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2013 CPS Benefits New Hire Packet
Planning Worksheet for Online Benefits Enrollment
ELECTIONS MUST BE MADE ONLINE
E M P L O Y E E ID N O .:
MEDICAL CHOICES:
E M P L O Y E E O NL Y
E M P L O Y E E +O N E
FAMILY
BlueCross BlueShield of Illinois PPO
□
□
□
UnitedHealthcare PPO
□
□
□
UnitedHealthcare PPO with health reimbursement account (HRA)
□
□
□
BlueCross Blue Shield HMO IL
□
□
□
□
□
□
Primary Care Physician 3-digit Group/IPA#: __________________
(required for HMOs)
UnitedHealthcare HMO
Primary Care Physician Code: __________________
(required for HMOs)
DENTAL CHOICES:
E M P L O Y E E O NL Y
E M P L O Y E E +O N E
FAMILY
Delta Dental of Illinois PPO
□
□
□
Delta Dental HMO
□
□
□
Primary Care Facility Number Site: _______________ (required for HMOs)
VISION BENEFITS:
Basic Vision Plan
E M P L O Y E E O NL Y
E M P L O Y E E +O N E
FAMILY
(Automatic, if you are enrolled in one of the medical plans)
Enhanced Vision Plan (Must be enrolled in a medical plan)
□
□
□
LONG-TERM DISABILITY INSURANCE:
90-Day Wait Option
□
180-Day Wait Option
□
F LEXIBLE S PENDING A CCOUNTS :
Flexible Spending—Health………………………………………………….Annual Contribution Amount
Flexible Spending—Dependent Care………………..…………………Annual Contribution Amount
LIFE AND PERSONAL ACCIDENT INSURANCE (PAI)
1X
2X
3X
4X
Optional Term Life
□
□
□
□
PAI
□
□
□
□
Spouse Life ($50,000)
□
PAI – Spouse
□
Dependent Life ($10,000)
□
Dependent PAI only ($10,000)
□
GROUP LEGAL SERVICES
(ARAG Group)
□
19
2013 CPS Benefits New Hire Packet
Dependents
In the space below, list your eligible dependents that you wish to enroll under your health coverage.
Dependent Name
Relationship
Date of Birth
Social Security
Medical Election
Dental Election
There Are Many Benefits to Starting Early . . .
Easier access to online computer systems. Employees who wait until the last few days, or even the last week, may
encounter delays.
Calmer, more thoughtful, process. If you start your benefits enrollment early, you will have ample opportunity to
consider all your options, and to see if your doctor is in your plan.
Easier access to Employee Services Team (773) 553-HR4U. For best service, allow yourself ample time to call the
hotline, because at times phones may be busy. One of our representatives will be happy to assist you.
More time to deliver your documents after you’ve made your selections. Remember, if you choose to add a
spouse, dependent, civil union or same sex domestic partner to your benefits, proper documentation must be
submitted to complete processing.
Computer Systems Requirements for Enrollment
Overview: Benefits enrollment is computer based only. Paper or telephone submissions are not accepted. Most modern
computers purchased in the last seven or eight years, with internet access will work just fine, whether at CPS public
schools, at the public library, or in your own home.
Details: Benefits enrollment works with a Windows, Macintosh, or even a Linux computer. Windows computers should
be equipped with Windows 98, 2000, or XP and one of the following browsers:
Internet Explorer 6 or later
Netscape 7 or Later
Firefox 1.0 or later
Google chrome 1.0.154 or later
Macintosh computers should be running Mac OS X and one of the following browsers:
Safari 1.2, 2.0, or later
Firefox 1.0 or later
Camino 1.0 or later
Netscape 7.0 or later
Google chrome 1.0.154 or later
Linux computers should have one of the following browsers:
Netscape 7.0 or later
Firefox 1.0 or later
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2013 CPS Benefits New Hire Packet
Documentation
Requirements
Great News! You can fax or scan your documentation!
CPS employees have the ability to scan and fax in their documentation 24 hours, 7 days a week. This is a
convenient and secure method of submitting your documentation without having to make a special trip
downtown!
To submit your documentation, click to access your personalized Scanning Cover Sheet
https://cpsatworkprod.cps.k12.il.us/psp/cpshrprd/EMPLOYEE/HRMS/c/CPS_IPM_FAX_MENU.CPS_SS_IPM_FA
X_CMP.GBL, complete and submit it with your documents either by fax to 773-553-4DOC or by scan to
benefitdocuments@cps.edu. Your documentation must be submitted within 31 days following your date of
hire in order to complete processing.
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2013 CPS Benefits New Hire Packet
Benefit Participant
Being Added
Spouse
Dependent (0–26 yrs.)
Unmarried Military Dependent Children
who are Residents of Illinois (Age 26–30)
(Benefits terminate at the end of the
month in which the 30th birthday
occurs)
Adopted Children
Legal Dependents
(Court Appointed)
Civil Union Partner
Domestic Partner
Document(s) Needed
An original certified Marriage Certificate
An original certified Birth Certificate (with parental information)
An original certified Birth Certificate
AND
A notarized Employee Certification Form
AND
Military discharge paperwork (DD2-14)
If the child is your adopted child and the birth certificate has not yet been
amended to name you and other adoptive parent as the child’s parents,
then the letter issued by the governmental agency placing the child in your
home will suffice for documentation, until such reasonable time as the
amended birth certificate can be issued.
You do not need to prove your relationship to the child’s parents if you are
the child’s legal guardian. You must provide a copy of the guardianship
appointment certified by the clerk of the court in which the appointment
occurred.
An original certified Civil Union certificate
Proof of domestic partnership is required. To determine if your Partner
qualifies for enrollment, the following eligibility requirements must be met:
o You must be enrolled in a CPS sponsored medical or dental plan;
o You must submit a completed Affidavit of Domestic Partnership and
meet the eligibility requirement for a Domestic Partner.
o You must submit certified Birth Certificates and copies of your Illinois
driver’s licenses or State of Illinois Identification Cards for both you and
your partner.
Your affidavit needs to meet the minimum requirements listed below:
o You and your partner are each other’s sole domestic partner,
responsible for each other’s common welfare;
o Neither you nor your Partner are married (if you or your partner were
previously married proof of dissolution of marriage is required)
o You and your Partner are not related by blood closer than would bar
marriage in the State of Illinois;
o You and your Partner are at least 18 years of age, are the same sex and
reside at the same residence;
AND
At least two of the following four conditions must apply:
o You and your partner have been residing together for at least twelve
(12) months prior to filing the Affidavit of Domestic Partnership.
o You and your partner have common or joint ownership of a residence.
o You and your partner have at least two of the following arrangements:
 Joint ownership of a motor vehicle;
 Joint credit account;
 Joint checking account;
 Lease for residence identifying both you and your Partner as
tenants.
o You declare your partner as a primary beneficiary in your will.
22
2013 CPS Benefits New Hire Packet
FRAUDULENT ACTS
It is a fraudulent act to provide documentation to establish the eligibility of a person who is not eligible for coverage
or if you fail to notify Chicago Public Schools that a formerly eligible person is no longer eligible within 31 days of the
date on which that person becomes ineligible. Suspected acts of fraud will be reported to the Office of the Inspector
General and are grounds for termination. The employee will also be held responsible for any PPO claims or HMO
premiums paid on behalf of an ineligible person.
All required documents can be faxed or scanned to (773) 553-4DOC or benefitdocuments@cps.edu.
Documents may also be walked in or mailed to:
Chicago Public Schools
Talent Office
The Benefits Employee Services Team
320 N. Elizabeth St., 1st Floor
Chicago, IL 60607
Mail Run # 38
23
2013 CPS Benefits New Hire Packet
BENEFITS PROVIDER CONTACT INFORMATION
The CPS Benefits Employee Services Team is your primary resource for benefits questions. If you have questions about
claims, doctors, or hospital locations, you may contact one of our providers.
24
Provider/Group Number
Phone Number
Address
Website
BlueCross/BlueShield HMO
(Medical: H12709)
BlueCross/BlueShield PPO
(Medical: P12709)
1-866-248-3092
P.O. Box 1364
Chicago, IL 60690
www.bcbsil.com/members
1-800-331-8032
P.O. Box 2352
Chicago, IL 60690
www.bcbsil.com/members
UnitedHealthcare (Medical)
HMO (EPO): 705789
PPO: 705706
PPO w/ HRA: 705708
Delta Dental
HMO/PPO: 10083
Caremark
(Prescription Carrier: CPSRX
1-800-905-4619
P.O. Box 30555
Salt Lake City, UT 84130-0555
www.myuhc.com
1-800-323-1743
P.O. Box 5402
Lisle, IL 60532-5402
www.deltadentalil.com
1-866-409-8523
P.O. Box 686005
San Antonio, TX 78268-6005
www.caremark.com
VSP
(Vision Service Plan)
1-800-877-7195
3333 Quality Drive
Rancho Cordova, CA 95670
www.vsp.com
Telligen
(Utilization Management)
1-888-781-9458
6000 Westown Parkway
West Des Moines, IA 50266-7771
http://Telligen.Qualitrac.com
United Behavioral Health/Optum
(Mental Health & Substance
Abuse)
1-800-711-6087
9700 Bissonnet
Suite 2300/2500
Houston, TX 77036
www.liveandworkwell.com
The Standard
(Life: 648354
and Disability)
Benefit Express
(Flexible Spending Accounts)
1-800-368-1135;
1-847-517-9458
920 SW Sixth Avenue
PSB9A
Portland, OR 97204
www.standard.com
1-877-837-5017
220 W. Campus Dr.
Suite 203
Arlington Heights, IL 60004
www.CPSFSA.com
ARAG
(Group Legal Services)
Bright Start
(College Savings Program)
Great-West Retirement Services
(Annuity)
VALIC
(Annuity)
ING
(Annuity)
MetLife
(Mutual Fund)
1-800-247-4184
www.araggroup.com
1-800-655-4853
www.brightstartsavings.com
1-877-649-4338
www.cpsretirementplans.com
1-800-892-5558
Ext. 88815
www.valic.com
1-800-873-9150
www.ingretirementplans.com
1-800-543-2520
www.mlr.metlife.com
2013 CPS Benefits New Hire Packet